At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Constipation

Indigestion

Swollen ankles

Urinary frequency

None

Answer and Explanation

The Correct Answer is B

A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.

B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.

C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."

D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.

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Correct Answer is D

Explanation

A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.

B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.

C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.

D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.

A. Levothyroxine for hypothyroidism B. Phenytoin for seizure disorder C. Magnesium oxide for constipation D. Ferrous sulfate for chronic anemia

Correct Answer is B

Explanation

A. Levothyroxine is a thyroid hormone replacement medication commonly used to treat hypothyroidism. It is not associated with teratogenic effects when used appropriately.

B. Phenytoin is an anticonvulsant medication that is known to be teratogenic, especially when used during the first trimester of pregnancy. It is associated with an increased risk of congenital malformations, such as cleft palate and heart defects, in infants born to mothers who take the medication during pregnancy.

C. Magnesium oxide is a mineral supplement commonly used to treat constipation during pregnancy. It is not associated with teratogenic effects when used appropriately.

D. Ferrous sulfate is an iron supplement commonly used to treat chronic anemia during pregnancy. It is not associated with teratogenic effects when used appropriately.

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At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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